Although contraception has traditionally been the responsibility of women, men have been involved in decisions about contraception for centuries: Withdrawal is described in the Bible; (1) periodic abstinence was reportedly used in ancient India; (2) and the precursor to the condom--a decorative sheath worn over the penis by Egyptians--dates back to 1350 B.C. (3) These methods cannot be used without the complete cooperation of men.
Female contraceptive methods have also been used for centuries, but women did not gain reliable control of their reproductive capability until modern methods--the pill and the IUD--became widely available in the 1960s and 1970s. Along with the sexual freedom women achieved with the use of these methods came the responsibility for preventing pregnancy. Men, no longer required to use condoms or to practice withdrawal, were essentially absolved from contraceptive decisions.
Consequently, both researchers and service providers have focused almost exclusively on women. Even in studies of couples testing the efficacy of condoms, the women were taught how to use condoms, while their partners had no contact with instructors. (4) "Most of our focus has been on women, and men have been the silent partners," says Jacqueline Darroch Forrest, vice president for research at The Alan Guttmacher Institute (AGI). "We don't even have a term for men who are involved in a pregnancy."
Although some studies of sexual activity and contraceptive use have included men, (5) few have examined men's attitudes about contraception and pregnancy. It was not until recently, in response to the outbreak of AIDS and other sexually transmitted diseases (STDs) and to high rates of unintended pregnancy among teenagers, that researchers and program directors began looking at men's role in contraceptive decisions. Men, who are now being asked to use condoms to prevent the spread of STDs and who are being held financially responsible for any offspring, are gradually coming back into the picture. The challenge today is to bring men back into a realm from which they have been excluded for years.
Many questions about men and contraception remain unanswered: Should men be involved in contraceptive decision-making and, if so, to what extent? Do men want to be involved, or would they prefer to leave this responsibility to women? What are men's concerns regarding contraception and how do they differ from women's? Can services for men be provided by family planning clinics, which have focused on women since the pill became available?
To begin to answer some of these questions, AGI convened several prominent researchers, policymakers and program directors in September 1993 to exchange information about men's needs, desires and concerns regarding contraception and how their attitudes affect their sexual behavior and that of their partners. The discussion, which is part of a larger project being conducted by AGI to learn more about men and contraception and to bring new attention to the issues facing sexually active couples, also provided a forum for researchers and program providers to determine future directions involving men and reproductive health.
"While everyone uses a contraceptive method at some time in their life, people are using them poorly and haphazardly," says Jeannie I. Rosoff, president of AGI. "We have looked at structural barriers to providing family planning services, contraception in particular, but also legislation and the mechanics of service provision. We have not spent much time examining personal behavior and what's behind it. What is the transaction between men and women when contraceptives are not used?"
WHY INVOLVE MEN?
In response to the question "Why should we involve men in contraceptive decision making?" each participant at the meeting gave a reason that stemmed from his or her perspective in the field. Some participants said that there is not enough evidence that involving men in contraceptive decisions improves use and reduces unwanted pregnancy, and called for more research before providing services for men. Others stated, on the contrary, that more program provision and evaluation is needed and that additional research is extraneous if programs are not developed.
Perhaps the most salient answer to the question was offered by Robert Johnson, director of Adolescent and Young Adult Medicine at New Jersey Medical School in Newark: "Men are already involved and we have to understand how they're involved" to meet their needs and society's more effectively. Other participants went on to list reasons related to health care, paternal responsibilities, cultural issues and more global concerns.
HEALTH CARE
Many participants believe that men will not take responsibility for contraception until society considers and treats them as an integral part of reproductive health care. "Men are not really in denial of their role [in contraception]," explains Ann Plunkett, former project director of the Young Men's Reproductive Health Study at Kaiser Permanente's Center for Health Research in Portland, Ore. "When you say to them 'reproductive health' they don't understand [what you mean]; they don't acknowledge that they're a part of that." Plunkett advocates socializing young men to realize their reproductive responsibility by encouraging fathers to talk to their sons and by including men's reproductive health in the health care system.
"If we could be indicted for neglect, we would be indicted for neglecting the role of men in reproduction and sexuality," asserted Jane Johnson, vice president of affiliate services for Planned Parenthood Federation of America. Johnson also brought attention to negative connotations surrounding men and contraceptive issues: Men are given the message that if they have sex, and a pregnancy results, they are going to be punished with child-support payments. Johnson elaborated, "We never give young men much of an opportunity to contemplate their right to choose whether or not to parent; it is imposed on them." In conversations with young men across the country, Johnson learned that most would not be pleased if their girlfriend became pregnant because they were not ready for parenthood.
Bruce Armstrong, (A) who has headed the Young Men's Clinic at Columbia Presbyterian Medical Center in New York City since its inception in 1985, noted that men tend to neglect their health in general and that the lack of services only adds to the problem. "Men are so underserved in reproductive issues. If they are such a major part of the 'problem,' they should be part of the solution." Armstrong added that men, particularly adolescents, need a place where they can discuss sexual issues, in addition to obtaining physical examinations and contraceptives. Armstrong reported that about 85-95% of the population served by the clinic--men aged 14-22--are sexually active and face a multitude of problems. "Often their beliefs get in the way of using contraceptives. Many young men fear that their partner will be insulted if they attempt to use a condom."
The idea that men should be included in reproductive health because it is an important aspect of comprehensive health care was proposed by several participants. According to Robert Johnson, men have a right to comprehensive health care, and they will utilize services if they are available. "Men should be involved because it's the right thing to do," Johnson asserted. "The health field does not recognize male sexual health as an issue."
Johnson is also chairman of the medical board for The Door, a multiservice facility that provides medical, recreational, legal and job counseling for youth in New York City. The Door began providing physical examinations of adolescent males in the 1970s, according to Johnson. "When we first started doing physical examinations, we were told that none of [the young men] would ever come back. We found that young men came back every six months for physical examinations just because we told them that this is what they need to do." He added, "In schools that have good condom distribution programs, the younger students use condoms more consistently. It proves that if you provide services for men, they will be accepted."
Young women are usually examined by a gynecologist when they first become sexually active, but no comparable service for men exists. According to Wayne Pawlowski, director of training at Planned Parenthood of Metropolitan Washington, even when men seek services for STDs, physicians do not discuss sex. "Almost no physicians [at an STD clinic] asked men who had STDs about their sexual behavior." He added that family planning providers are hostile toward men. "When you get a different perspective between what the guy says and what his partner says, everybody believes her, whether it's true or not."
